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Max C. Lee, Michael Y. Wang, Richard G. Fessler, Jason Liauw and Daniel H. Kim

Object

Placement of instrumentation in the setting of a spinal infection has always been controversial. Although the use of allograft and autograft bone has been accepted as safe, demonstrations of the effectiveness of titanium have been speculative, based on several retrospective reviews. The authors' goal in this study was to demonstrate the effectiveness of instrumentation in the setting of a spinal infection by retrospectively reviewing their cases over the last 4 years and searching the literature regarding instrumentation in patients with pyogenic spinal infections.

Methods

The authors conducted a retrospective review of their cumulative data on spinal infections. Diagnosis was based on subjective and objective clinical findings, along with radiographic and laboratory evaluation of infection and mechanical stability. Patients with medically managed disease and those who did not receive instrumentation were eliminated from this review.

Of 105 patients with spinal infections who were admitted to the neurosurgical service between January 2000 and June 2004, 30 underwent surgical debridement necessitating spinal instrumentation. There were 17 women and 13 men in this group ranging from 28 to 86 years of age. Follow-up duration ranged from 3 to 54 months. There was one death, which occurred 3 months postsurgery. In three patients a deep wound infection developed, necessitating intervention, and two patients experienced a graft expulsion. Twenty-nine patients went on to demonstrate adequate fusion based on follow-up neuroimaging studies.

Conclusions

The goal of neurosurgical intervention in the setting of spinal infection is to obtain an organism culture and the debridement of infection while maintaining neurological and mechanical stability. The authors demonstrate the effectiveness of radical debridement of infected bone and placement of instrumentation in patients with spinal infections.

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Donald D. Dietze Jr., Richard G. Fessler and R. Patrick Jacob

S pinal osteomyelitis is found in 2 to 7% of all cases of osteomyelitis and in adults represents the most common site for hematogenously acquired osteomyelitis. 5, 21, 24, 30, 34 Management goals for spinal infections (discitis, osteomyelitis, epidural abscesses) are as follows: 1) preservation of neurological function; 2) prevention of sepsis; 3) permanent eradication of infection; and 4) spinal stabilization. Aggressive debridement of abscesses and parenterally administered antibiotic drugs maximize the prevention of sepsis and eradication of infection

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John E. O'Toole, Kurt M. Eichholz and Richard G. Fessler

P ostoperative SSIs are some of the more common complications after spinal surgery. 4 , 26 , 34 , 35 Reported rates of spinal SSIs in the literature have ranged from 0.7 to 16%. 2–5 , 8 , 10–12 , 14 , 18 , 19 , 21 , 25 , 26 , 28 , 30 , 31 , 34 , 35 , 38 , 39 , 41 , 42 , 48 , 49 , 51 These infections can be challenging to treat and often require prolonged antibiotic therapy, extended hospitalizations, and repeated operations for wound debridement, hardware removal, or delayed complications of infection. All of this serves to increase health care resource

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Donald D. Dietze Jr., M.D., Richard G. Fessler and R. Patrick Jacob

Primary reconstruction using bone grafts and instrumentation for spinal infections remains controversial. Between 1991 and 1993, 27 infections of the spinal column were treated at the Department of Neurosurgery of the University of Florida. Of the 27 cases 20 (six cervical, eight thoracic, and six lumbar spine) required surgical debridement and spinal reconstruction to maximize eradication of the infection and maintenance of spinal alignment. All of the cervical and lumbar cases were caused by bacterial infections, and two of eight thoracic cases were caused by tuberculous infections. Spinal arthrodesis was performed in all cases: interbody grafts were used in 18 procedures and posterolateral onlay grafts in 14. Interbody grafts were autologous in 10 cases (six rib and four iliac crest) and homoplastic in eight (six fibular and two humerus). All of the posterolateral onlay grafts were autologous (three rib and 11 iliac crest). Spinal instrumentation was used in 15 cases: four with Caspar plates and 11 with posterior segmental fixation (five hook/rod constructs and six screw/rod constructs). Seventeen of 20 patients achieved improved clinical status postoperatively and 18 of 20 showed radiographic evidence of bone fusion. Antibiotic drugs were administered parenterally for an average of 6 weeks followed by a 3-month course of oral antibiotic medications. Tuberculous infections were treated for 1 year with antibiotic therapy. The average follow-up period was 37 months from surgery and 31 months after completion of treatment with antibiotic drugs. The authors conclude that primary arthrodesis and instrumentation can be performed in acute spinal infections; however, successful management depends on aggressive debridement of infectious foci and prolonged treatment with parenteral antibiotic drugs.

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Justin S. Smith, Alfred T. Ogden and Richard G. Fessler

, restoration of the posterior tension band when indicated, and fusion. Current surgical treatment of spine trauma typically involves conventional open exposures with placement of instrumentation and fusion. A recent systematic review of the surgical management of thoracolumbar trauma by Verlaan and colleagues 76 suggests that patients with trauma may be particularly susceptible to increased operative blood loss and infection. In this review the median blood loss was in excess of 1 liter for posterior, anterior, or combined anterior–posterior procedures, and infection rates

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Curtis A. Dickman, Richard G. Fessler, Michael MacMillan and Regis W. Haid

, for scoliosis in five, or for intradural tumor in one. Patients with fractures, infection, or tumor usually presented with acute or subacute symptomatic pathology characterized by sudden onset of back pain, neurological deficits, and spinal deformities. Patients with acute pathology who had a greater than 50% loss of vertebral body height, more than 30° of vertebral angulation, or a vertebral subluxation over 10 mm were considered for surgery without a trial of nonsurgical therapy. Patients with acute neurological deficits were managed with operative intervention as

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Srinath Samudrala, Larry T. Khoo, Seung C. Rhim and Richard G. Fessler

Procedures involving anterior surgical decompression and fusion are being performed with increasing frequency for the treatment of a variety of pathological processes of the spine including trauma, deformity, infection, degenerative disease, failed-back syndrome, discogenic pain, metastases, and primary spinal neoplasms. Because these operations involve anatomy that is often unfamiliar to many neurological and orthopedic surgeons, a significant proportion of the associated complications are not related to the actual decompressive or fusion procedure but instead to the actual exposure itself. To understand the nature of these injuries, a detailed anatomical study and dissection was undertaken in six cadaveric specimens. Critical structures at risk in the abdomen and retroperitoneum were identified, and their anatomical relationships were categorized and photographed. These structures included the psoas muscle, kidneys, ureters, diaphragm and crura, esophageal hiatus, thoracic duct, greater splanchnic nerves, phrenic nerves, sympathetic chains, medial arcuate ligament, superior and inferior hypogastric plexus, segmental and radicular vertebral vessels, aorta, vena cava, median sacral artery, common iliac vessels, iliolumbar veins, lumbosacral plexus, and presacral hypogastric plexus. Based on these dissections and an extensive review of the literature, the authors provide a detailed anatomically based discussion of the complications associated with anterior lumbar surgery.

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Richard G. Fessler, Donald D. Dietze Jr., Michael Mac Millan and David Peace

are preserved and serve as protective barriers to the thecal sac and superior mediastinal structures ( Fig. 3D ). Vertebral reconstruction is performed using a rib graft strut if the pathological process is benign (for example, in cases of infection or compression fracture) or using Steinmann pins and methyl methacrylate if the pathological process is malignant ( Fig. 3E ). The nerve roots are ligated proximal to the dorsal root ganglion and the nerve is removed with the dorsal root ganglion. Ligation of the spinal nerves proximal to the dorsal root ganglion should

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John C. Steck, Donald D. Dietze and Richard G. Fessler

resection of vertebral metastatic lesions of the upper thoracic spine, as well as for trauma, infection, and disc herniation. 5, 6 These posterolateral approaches provide simultaneous exposure of the ventral, lateral, and dorsal aspects of the spinal canal at any level of the thoracic spine. They do not require violation of the pleural space, manipulation of the mediastinal structures, or vertebrectomy, and they enable immediate posterior stabilization, if necessary. In the patients in our series, the posterolateral approach was extended to resect ventrally located

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Curtis A. Dickman, Jacqueline Locantro and Richard G. Fessler

‡ 8 new postop 5 4 † 2 § 11 none postop 1 6 1 ‖ 8 total cases 11 11 5 27 * This patient had Down's syndrome. † Only one of these four patients was initially unstable after transoral surgery; three (with a Chiari malformation) became unstable only after subsequent posterior decompressive surgery. ‡ Cases of plasmacytoma and infection. § Two cases of odontoid fracture/malunion. ‖ This patient received a gunshot injury. Nineteen patients (70%) demonstrated